Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
  • AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Care of Patient in Restraints
    Automated Med Dispensing Systems
    Other Automated Med Dispensing Systems:
    Electronic Documentation
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    Cardiac Monitoring/Interpretation
    PCA/Epidural pumps
    Titration of drips
    Administration of Blood/Blood Products
    Infant/Neonatal Cardiac/Respiratory Arrest
    Adult Respiratory/Cardiac Arrest
    Care of Patient in Restraints
    Knowledge of "Do Not Use Abbreviations"
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    ANTEPARTUM ASSESSMENT/CARE
    Non Stress Test
    Fetal Heart Rate Interpretation and Management
    Contraction Patterns
    Preterm Labor
    Premature Rupture of Membranes
    Cardiac disease
    Diabetes
    PIH/HELLP
    Placenta Previa/Abruptio
    Fetal Assessment
    Labor Assessment
    Substance abuse
    Hyperemesis
    Multiple births
    MEDICATIONS KNOWLEDGE AND USE OF
    Oxytocin/Pitocin
    Terbutaline
    Magnesium Sulfate
    Cervical Ripening Agents
    POST PARTUM MATERNAL ASSESSMENT/CARE
    Vital Signs/Pulse Oximetry
    Care of Post-Op Tubal Ligation Patient
    Care of Post C-section Patient
    Care of Post Vaginal Delivery Patient
    Care of Patient with Postpartum Hemorrhage
    Care of Patient with Fetal Demise
    Care of patient with epidural
    Post anesthesia care (Epidural, General, Local, Spinal)
    Breast Care
    Fundal Assessment
    Lochia Assessment
    Episiotomy Assessment/Care
    Perineum Assessment/Care
    Bowel Function Assessment
    Bladder distention Assessment
    Insertion of catheter (foley or straight)
    Assessment for DVT
    POSTPARTUM CARE OF THE MOTHER WITH
    Asthma
    Cardiac disease
    Diabetes
    PIH
    Substance abuse
    Infectious disease
    Multiple births
    NEWBORN ASSESSMENT/CARE
    Infant identification
    Vital signs
    Length/Weight/Chest/Head
    Ballard scale score
    Dubowitz scale score
    Administer injections to neonate
    Bathe infant
    Reflexes
    Thermal-neutral environment to prevent stress
    Incubator/Isolettes
    Respiratory Distress
    Bulb Suction
    Monitor bladder and bowel patterns
    Bonding Behaviors (Mother/Infant)
    Assist with circumcision
    Assess post op circumcision
    CARE OF THE INFANT WITH
    Possible Infectious Process
    Neonatal Jaundice/Phototherapy
    Drug Addiction/Withdrawal
    Temperature Regulation Problems
    PHLEBOTOMY AND IV THERAPY
    Insertion, Care and Maintenance of Peripheral IV
    Care of the patient with central line
    Drawing venous blood
    Heelstick
    Drawing blood from central line
    Administration of Blood/Blood Products
    MEDICATIONS KNOWLEDGE AND USE OF
    Antibiotics
    Insulin (IV and SQ)
    Oxytocin
    Rhogam
    Analgesics
    Reversal Agents
    PCA for Analgesia
    PATIENT EDUCATION
    Breastfeeding
    Latch-on procedures
    Positioning
    Use of electric breast pump
    Use of manual breast pump
    Formula preparation and feeding
    Infant caretaking skills
    Teach circumcision care to parents
    Contraceptives
    Discharge Planning and Infant Requirements